Consensus | neuropad

International Neuropathy Workshop of 2009

Introduction

The International Consensus Workshop in Toronto in 2009 arose from the fact that at the moment there are no clear, universally accepted guidelines regarding the definition of diabetic neuropathies. This has resulted in a massive variation in how neuropathy is diagnosed in different centres and countries.
A preliminary summary report of the Toronto meeting was published in 2010. The series of papers published in this issue of Diabetes/Metabolism Research and Reviews are the detailed reports that came from each sub-group of this Consensus panel. These reviews cover the problems with definitions and classification of neuropathy, the management of painful neuropathy and then the sub-group of small fibre neuropathies.

This series of papers will give the reader detailed information on the diverse aspects of diabetic neuropathies, their measurement and management, and will also assist in the selection of appropriate measures of both autonomic and somatic nerve function in clinical trials.

DIABETES/METABOLISM RESEARCH AND REVIEWS INTRODUCTION

Diabetes Metab Res Rev 2011; 27: 617–619.

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/dmrr.1228

Sudomotor

Dysfunction

Management strategies for gastrointestinal, erectile, bladder, and sudomotor dysfunction in patients with diabetes.

Clinical manifestations

...Sudomotor dysfunction is associated with dry skin and itching and may impair QoL and is associated foot ulceration in diabetes...

Diagnosis

The indicator plaster represents a rapid, simple method based on the colour change of a cobalt II compound from blue to pink, after 10 min exposure

to dermal foot perspiration at the plantar foot regions.

Indicator plaster response correlated [54] with neuropathy disability score (p < 0.001), neuropathic symptom score (p = 0.03), cold detection threshold (p = 0.003), heat-as-pain perception threshold (p < 0.043) and deep-breathing HRV (p < 0.00). Intra-epidermal nerve fibre density compared with age- and sex-matched control subjects was significantly reduced in patients with patchy/absent response (p = 0.02). The authors concluded that the indicator plaster may serve as a simple indicator for screening patients with diabetic neuropathy (C). Indicator plaster results correlate well with the presence of peripheral sensorimotor neuropathy and to lesser degree with indications of CAN (Table 2, references are shown in Supporting information). Although indicator plaster specificity was lower in most studies, it was comparable with other established methods (Class II and III); nonetheless, reference methods were different in the various studies.

Recomandations

...The indicator plaster represents a rapid, simple method based on the colour change of a cobalt II compound from blue to pink, after 10 min exposure to dermal foot perspiration at the plantar foot regions....

DIABETES/METABOLISM RESEARCH AND REVIEWS REVIEW ARTICLE

Diabetes Metab Res Rev 2011; 27: 665–677.

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/dmrr.1223

Small fibre

neuropathy

Small fibre neuropathy: role in the diagnosis of diabetic sensorimotor polyneuropathy

Summary

Small fibres constitute 70–90% of peripheral nerve fibres and regulate several key functions such as tissue blood flow, temperature and pain perception as well as sweating, all of which are highly relevant to the clinical presentation and adverse outcomes associated with foot ulcerations in patients with diabetes...We have therefore critically assessed currently available techniques that measure small fibre dysfunction in diabetic neuropathy,

using quantitative sensory and sudomotor testing...Finally, we propose a definition for diabetic neuropathy that incorporates small fibre damage

Diabetic neuropahty

...In patients with diabetic neuropathy, the prevalence of abnormal nerve conduction, Quantitative Sensory Testing and IENF was comparable [35]. However, IENF density was significantly reduced in patients with normal nerve conduction, suggesting early damage to small nerve fibres [12,14]. A recent study has shown comparable abnormalities in electrophysiology thermal thresholds and loss of IENF in diabetic patients with mild neuropathy [35]. There is an inverse correlation between IENF density and the severity of DSPN, defined by the Neurological Disability Score [13,29,47] and the Neuropathy Impairment Score [14]. Additionally, IENF density appears to be lower in diabetic patients with painful neuropathy compared with painless neuropathy [13,29,48]. A 1-year diet and exercise intervention program in patients with SFN and impaired glucose tolerance led to increased IENF density...

Sudomotor innervation

Recently, a novel stereologic technique has been applied in skin biopsies and showed a correlation between sweat gland nerve fibre density, neuropathic symptoms, neurological deficits and sweat production...

Neuropad

The neuropad test is a simple visual indicator test which uses a colour change to define the integrity of skin sympathetic cholinergic innervation. Neuropad responses have been shown to correlate with modified NDS, Quantitative Sensory Testing, cardiac autonomic neuropathy and IENF loss with relatively high sensitivity but lower specificity for detecting DSPN [68,69]. A recent study has shown that an abnormal result of Neuropad test in those with a normal NDS may predict the development of diabetic neuropathy after 5 years [70]. This appears to reflect early small fibre involvement which is missed using NDS as a measure of neuropathy.

DIABETES/METABOLISM RESEARCH AND REVIEWS REVIEW ARTICLE

Diabetes Metab Res Rev 2011; 27: 678–684.

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/dmrr.1222